► Approximately 10 million US adults have a Serious Mental Illness (SMI). These individuals have higher rates of morbidity and shorter life-expectancies than the general population.…
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▼ Approximately 10 million US adults have a Serious
Mental Illness (SMI). These individuals have higher rates of
morbidity and shorter life-expectancies than the general
population. Persons with SMI are at increased risk of visiting the
emergency room and being hospitalized due to multiple
comorbidities; and, inconsistent or nonexistent use of outpatient
services. To address health disparities, section 2703 of the
Affordable Care Act allocated funds for Health Homes (HH),
patient-centered care that afford the chronically ill with
comprehensive behavioral and primary care services. This
dissertation describes an evaluation of Rhode Island’s (RI) HH
program, which provided coordinated and integrated care to Medicaid
beneficiaries with SMI who used community mental health centers
(CMHC) as their medical home. The aims of this dissertation were 1)
evaluate the extent to which HH impacted outpatient service use; 2)
establish the degree to which hospital and emergency department use
were affected by HH; and 3) identify the care setting that impacted
health services use among HH participants. Using RI Medicaid claims
(2009-2012) and a quasi-experimental difference-in-differences
approach with propensity score weighting, health service use was
evaluated before and after the introduction of HH. In Chapter 1,
findings suggest HH was associated with an increase in outpatient
service use, overall and for visits associated with obesity and
chronic obstructive pulmonary disease. Chapter 2 results showed HH
was associated with a decrease in the proportion having a
hospitalization for acute ambulatory care sensitive conditions and
for non-mental illness conditions. Additionally, HH was associated
with a decrease in emergency department use for non-mental illness
conditions. Findings also indicated HH was associated with an
increase in the proportion having a hospitalization for a mental
illness as well as an increase in the number of emergency
department visits for all-cause and non-mental illness conditions.
In Chapter 3, results suggest HH participants within an integrated
care setting experienced a decrease in the proportion having a
hospitalization for all-cause and non-mental illness conditions.
Investment in CMHC based integration can improve access to and use
of outpatient services as well as decrease hospital and emergency
department use among Medicaid beneficiaries with SMI.
Advisors/Committee Members: Galárraga, Omar (Advisor), Wilson, Ira (Reader), Trivedi, Amal (Reader), Cook, Benjamin (Reader).

Wegman MP. Comparative Effectiveness of Managed Care on Quality of Care for Medicaid Adults with Disabilities. [Doctoral Dissertation]. University of Florida; 2017. Available from: http://ufdc.ufl.edu/UFE0051515

University of Southern California

3.
Mulani, Parvez.
Effects of a formulary expansion on the use of atypical
antipsychotics and health care services by patients with
schizophrenia in the California Medicaid Program.

► In October 1997, the California Medicaid Program (Medi-Cal) added atypical antipsychotics to its formulary to facilitate the substitution of the atypical antipsychotics for older medications…
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▼ In October 1997, the California Medicaid Program
(Medi-Cal) added atypical antipsychotics to its formulary to
facilitate the substitution of the atypical antipsychotics for
older medications as clinically warranted, especially in minority
patients thought to be particularly at risk for poor outcomes using
older medications. Moreover, it was expected that the overall use
of antipsychotics would increase as patients who experienced
suboptimal outcomes prior to the formulary expansion would again
seek treatment once new options were available. The formulary
expansion did significantly alter the clinical treatment decision
process, resulting in an immediate but temporary increase in the
number of patients initiating antipsychotic therapy, many with a
recent institutionalization, who restarted drug therapy using the
new antipsychotics. There were significant changes in the
characteristics of patients using antipsychotic medications. The
likelihood of minority patients i.e. African American's gaining
access to atypical antipsychotics improved substantially.
Persistence on initial antipsychotic decreased and total health
care costs increased following open access. However the magnitude
of the increase in costs was not uniform across all patient types.
Program administrators must use caution when evaluating the impact
of unrestricted access on drug therapy outcomes and treatment costs
given the changes in the characteristics of patients seeking
treatment.
Advisors/Committee Members: McCombs, Jeffrey S. (Committee Chair), Nichol, Michael B. (Committee Member), Graddy, Elizabeth A. (Committee Member).

Mulani, P. (2009). Effects of a formulary expansion on the use of atypical
antipsychotics and health care services by patients with
schizophrenia in the California Medicaid Program. (Doctoral Dissertation). University of Southern California. Retrieved from http://digitallibrary.usc.edu/cdm/compoundobject/collection/p15799coll127/id/223786/rec/2202

Chicago Manual of Style (16th Edition):

Mulani, Parvez. “Effects of a formulary expansion on the use of atypical
antipsychotics and health care services by patients with
schizophrenia in the California Medicaid Program.” 2009. Doctoral Dissertation, University of Southern California. Accessed January 21, 2019.
http://digitallibrary.usc.edu/cdm/compoundobject/collection/p15799coll127/id/223786/rec/2202.

MLA Handbook (7th Edition):

Mulani, Parvez. “Effects of a formulary expansion on the use of atypical
antipsychotics and health care services by patients with
schizophrenia in the California Medicaid Program.” 2009. Web. 21 Jan 2019.

Vancouver:

Mulani P. Effects of a formulary expansion on the use of atypical
antipsychotics and health care services by patients with
schizophrenia in the California Medicaid Program. [Internet] [Doctoral dissertation]. University of Southern California; 2009. [cited 2019 Jan 21].
Available from: http://digitallibrary.usc.edu/cdm/compoundobject/collection/p15799coll127/id/223786/rec/2202.

Council of Science Editors:

Mulani P. Effects of a formulary expansion on the use of atypical
antipsychotics and health care services by patients with
schizophrenia in the California Medicaid Program. [Doctoral Dissertation]. University of Southern California; 2009. Available from: http://digitallibrary.usc.edu/cdm/compoundobject/collection/p15799coll127/id/223786/rec/2202

► Background: Prenatal care (PNC) is an important preventive health service that can influence the health of the four million women who give birth annually in…
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▼ Background: Prenatal care (PNC) is an important preventive health service that can influence the health of the four million women who give birth annually in the United States, and the health their infants. Despite efforts to increase women’s access to PNC services, significant disparities in PNC utilization and maternal/child health outcomes by insurance type and race/ethnicity persist in the United States. The past decade has witnessed several major health reforms at both national and state levels. However, the impact of these reforms on the quality of PNC, and on disparities in PNC utilization is not known. In 2012, the state of Oregon established Coordinated Care Organizations (CCOs) as comprehensive providers of care for Oregon’s Medicaid beneficiaries. CCOs are characterized by a global budget payment mechanism and financial incentives for high quality care. Timely initiation of PNC – which has been associated with improved maternal and infant health and utilization outcomes – is one of seventeen quality metrics for which CCOs can receive incentive payments.
Objectives: The first objective of the current study was to estimate the impact of CCO implementation on the probability of initiating PNC in the first trimester, and on PNC adequacy among Oregon Medicaid beneficiaries. The second objective of the study was to determine if the implementation of CCOs influenced disparities in PNC utilization between Medicaid and privately-insured women, and between non-Hispanic White women and Hispanic/non-Hispanic Black women.
Study Design: This quasi-experimental retrospective observational study drew from two data sources: Oregon Vital Records (Birth Certificate statistical files) from the department of Health Analytics of the Oregon state public health department and Washington State’s Linked Birth- CHARS (Comprehensive Hospital Abstract Reporting System) data from the Washington State department of health. A difference-in-differences approach examined PNC utilization before and after CCO implementation. Washington State served as the control group, as its Medicaid financing and delivery systems remained unchanged. Multivariable linear probability analysis was used to control for confounding factors, including maternal age, race/ethnicity, education, parity, marital status, smoking history, previous preterm birth, and maternal morbidity.
Population Studied: All births in Oregon and Washington from 2008 – 2013, which were covered by either Medicaid or private insurance, were included in the analysis. Since CCOs started operating mid-year in 2012, June through December 2012 was considered a transition period and births during this period were excluded from the analysis.
Principal Findings: CCO implementation was associated with a significant increase in the probability of PNC initiation in the first trimester and a reduction in insurance-type disparities in first trimester PNC initiation and PNC adequacy among Oregon Medicaid beneficiaries. Racial/ethnic disparities did not change following CCO implementation.
…
Advisors/Committee Members: Luck, Jeff (advisor), Bernell, Stephanie (committee member).

► Asthma is a chronic disease whose effects are controlled/ prevented using appropriate medication. Although benefits of asthma medication is well known, poor medication adherence…
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▼ Asthma is a chronic disease whose effects are controlled/ prevented using appropriate medication. Although benefits of asthma medication is well known, poor medication adherence among asthma patients has been reported. Medication non-adherence is associated to increased healthcare costs, unnecessary hospital utilization, readmission and even death in few cases. The overarching goal of this research was to evaluate the impact of medication non-adherence on hospital admissions, and identify key factors that result in medication non-adherence for Medicaid insured asthma patients.
To achieve these objectives, Correlation analysis, T-tests, Multivariate logistic analysis and odds ratios were performed. Based on results of the study, the present study did not find significant relationships between control medication adherence and the different types of hospital visits (i.e. emergency department visits, inpatient admits, and readmission). However, patients with high rescue medication adherence had fewer emergency department visits (p-value=0.0004) and inpatient admissions (p-value=0.0303). Patients with more than 4 office visits had better rescue medication adherence, older and low-income patients had higher 30-day readmissions rate. While, male and low-income patients had emergency visits
Additionally, The two types of insurance coverage (Temporary Assistance for Needy Families and Supplemental Security Income-Non Dual) were the only significant predictors of control medication adherence among the factors analyzed (with p-values =0.0001). Asthma patients with TANF and SSI- Non Dual coverage are less adherent to control medication adherence compared to other coverage. Also, control and rescue medication adherence was not significantly different among case managed and non-case managed asthma patients.

► This project investigates the long-term effects of exposure to Medicaid in early childhood on adult health and economic status by leveraging the program's gradual adoption…
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▼ This project investigates the long-term effects of exposure to Medicaid in early childhood on adult health and economic status by leveraging the program's gradual adoption across the states. The staggered timing of Medicaid's introduction created variation in cumulative exposure to Medicaid for birth cohorts that are now in adulthood. I use this natural experiment in a generalized difference-in-differences framework that is complemented by a rich set of state-by-year and county-by-year controls that measure changes in public spending on the poor and health care supply. I demonstrate further support for the study design by comparing Medicaid's impact in groups that were targeted by the program versus groups that had a low probability of being eligible for benefits. I first examine the impact of Medicaid's introduction on short-run measures of utilization and infant health to establish that the program had short-term effects that could have persisted over time. Using data from the National Health Interview Survey I find that Medicaid increased the probability of any annual hospital stay by approximately 3 percentages points among low-income children under 6. Data from the National Natality Survey suggests that the program reduced the incidence of low-birth weight in the low-income population by 4 percentage points. Both findings provide evidence that the introduction of Medicaid created meaningful short-run benefits that could have persisted over time. To examine the program's long-term impacts I use data from the Panel Study of Income Dynamics. Results suggest that in subgroups targeted by the program, exposure to Medicaid in childhood (age 0-5) is associated with statistically significant and meaningful improvements in adult health (age 18-54). I find no evidence for an economic effect, but the point estimates are imprecise and the findings are inconclusive. I discuss the significance of my results in the context of a dynamic model of child development that interacts with an evolving U.S. health system.

Samuels, S. K. (2017). The Early Impact of Medicaid Expansion on Health Care Access and Utilization among Individuals with Ambulatory Care Sensitive Conditions. (Doctoral Dissertation). University of Florida. Retrieved from http://ufdc.ufl.edu/UFE0051821

Samuels SK. The Early Impact of Medicaid Expansion on Health Care Access and Utilization among Individuals with Ambulatory Care Sensitive Conditions. [Doctoral Dissertation]. University of Florida; 2017. Available from: http://ufdc.ufl.edu/UFE0051821

►Medicaid recipients may have complex, chronic conditions as well as significant medical and specialty service needs, particularly those with mental health disabilities. Care coordination is…
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▼Medicaid recipients may have complex, chronic conditions as well as significant medical and specialty service needs, particularly those with mental health disabilities. Care coordination is a core mechanism of integrated care that can increase access to services, reduce costs, and improve enrollee outcomes. This research study explores the impact of care coordination for Medicaid managed care enrollees with disabilities and mental health conditions on user-reported service delivery access and consumer experience quality outcomes. A quantitative analysis was conducted using primary data collected from consumer surveys of adults with disabilities in the Illinois Integrated Care Program (N=1,123). Of these Medicaid enrollee respondents, 476 received coordinated care through their managed care plan. Descriptive analyses of survey items describe response patterns of survey participants. Regression analyses are performed for the coordinated care group with dependent variables of total unmet needs and average health services appraisal. Study results show that more person-centered experiences with care coordination are associated with fewer unmet needs and better appraisals of their health care services overall in a Medicaid managed care population. Notably, significant differences in outcomes are also found for enrollees with mental health disabilities, with members of this group reporting more unmet needs and worse appraisals than those without mental health conditions. Findings from this study suggest enrollees with mental health disabilities may require focused attention in the application of person-centered care coordination to meaningfully enhance service access and consumer experiences in this user population. Research outcomes inform the future direction of state program policy and contribute to the development of quality reporting standards that prioritize accessible care and health equity for people with disabilities.
Advisors/Committee Members: Parker Harris, Sarah (advisor).

► Background: Malocclusion can affect an individual's quality of life. Unfortunately, access to orthodontic treatment is limited for many children. Access is improved when orthodontists select…
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▼ Background: Malocclusion can affect an individual's quality of life. Unfortunately, access to orthodontic treatment is limited for many children. Access is improved when orthodontists select practice locations where their services are most needed. Methods: A statistical model was applied to demographic and dental practice data in Kentucky to determine underserved areas that have the capacity to support additional orthodontic practices. All zip codes and practices were mapped using a geographic information system (GIS). Results: The model identified 30 underserved zip codes with practice-supporting capability, but this number fell to zero after additional verification. Sixteen counties (13.3%) contain areas located more than 30 miles from the nearest practice. Fifteen counties (12.5%) contain areas located more than 50 miles from a Medicaid orthodontic provider. Conclusions: Kentucky does not have a shortage of orthodontic practices, but certain regions could benefit from additional Medicaid providers. The statistical model, in conjunction with GIS, can assist in assessing practice site viability.
Advisors/Committee Members: Bednar, Eric D..

► Importance: Community Health Centers (CHC) are important sites of care for people living with HIV (PLWH) and play an increasing role in their care under…
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▼ Importance: Community Health Centers (CHC) are important sites of care for people living with HIV (PLWH) and play an increasing role in their care under the Affordable Care Act. Little is known about the relationship between CHC usage and emergency department (ED) utilization in this population. Objective: To determine the association between CHC usage and ED utilizationDesign: Retrospective, cross-sectional study of diagnosed PLWH enrolled in California’s Medicaid program in 2008 and 2009. Zero-inflated Poisson models were used to estimate the odds of being an ED user and the number of ED visits in 2009. We controlled for demographics (age, gender, race, urban residence, income, education), service characteristics (managed care enrollment, provider HIV experience), and medical characteristics (mental health, substance abuse, tobacco, medical comorbidity, antiretroviral therapy). Setting: Emergency department Participants: We included 6284 adult, full-term 2008-2009 beneficiaries with strong evidence of HIV diagnosis and excluded pregnant and dual-eligible beneficiaries. Exposures: CHC users were patients who had ≥1 CHC outpatient claim in 2008. Non-CHC users had outpatient claims only at non-CHCs. Those with no outpatient usage had no 2008 outpatient claims. Main Outcomes and Measures: Number of ED claims on separate days per beneficiary in 2009Results: CHC users averaged significantly greater numbers of ED visits than non-CHC users and those with no outpatient usage (1.91, 1.58, and 1.70, respectively; P=0.022). CHC users had higher odds of being ED users (OR=1.16; 95%CI 1.04-1.30). Controlling for demographic and service characteristics did not alter this result (OR=1.16; 95%CI 1.03-1.31). The difference was mitigated once medical characteristics were included (OR=1.09; 95%CI 0.96-1.25). The association between CHC status and number of ED visits, conditional on using the ED at all, was not significant in the bivariate (rate ratio (RR)= 1.12; 95%CI 0.97-1.28) or multivariate models (RR=1.01; 95%CI 0.87-1.17). The overall differences in mean ED visits observed between CHC and non-CHC groups were reduced to insignificance (1.77; 95% CI 1.60-1.93 vs 1.68; 95%CI 1.53-1.84) after adjusting for demographic, service, and medical characteristics. Conclusions and Relevance: CHC users had higher ED utilization than non-CHC users, but the disparity was largely driven by differences in medical characteristics.

▼ Hypothesis: There is no difference in patient compliance regarding appointment keeping behavior, broken appliances, wearing orthodontic auxiliaries, or oral hygiene maintenance in the Medicaid and non-Medicaid orthodontic populations studied.
Objective: To determine if perceived problems with the orthodontic Medicaid population are justified by examining whether patients whose orthodontic treatment is covered by Medicaid have more late and failed appointments, more broken appliances and are less compliant with orthodontic auxiliaries wear and oral hygiene maintenance than patients who are paying for orthodontic services themselves.
Methods: A retrospective chart review was conducted at two sites: 1) Wicker Park Orthodontics – a private orthodontic practice in Chicago and 2) the University of Illinois at Chicago Orthodontic Clinic. Charts of 30 Medicaid and 30 non-Medicaid patients were reviewed at each site. From each chart, the following information was recorded: mean percentage of failed and late appointments, number of broken appliances, auxiliary wear, and oral hygiene maintenance. Student t-tests and Chi-square tests were performed to determine if there were any statistically significant differences in the aforementioned categories between the Medicaid and non-Medicaid orthodontic patients.
Results: The student t-tests showed no statistically significant differences between the two groups with regards to the mean percentage of late and failed appointments (p = 0.107, p = 0.393). Cross-tabulation and Chi-square results also showed no statically significant differences between the two groups with regards to the number of broken appliances, auxiliary wear, and oral hygiene (p = 0.075-0.600).
Conclusions: The results of this study indicate there is a lack of evidence behind orthodontists’ perceptions that Medicaid orthodontic patients are less compliant than non-Medicaid orthodontic patients. While there are still some difficulties in treating Medicaid patients, such as low fee reimbursement and cumbersome paperwork, the current study will hopefully alleviate some of the doubts practitioners may have regarding this population’s compliance making them more open to participating in the Medicaid program to help reduce the access to care issue faced by these patients.
Advisors/Committee Members: Kusnoto, Budi (advisor).

► The purpose of this case study was to investigate the effects of community health workers (CHWs) on at-risk pregnant women in Muskegon County through a…
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▼ The purpose of this case study was to investigate the effects of community health workers (CHWs) on at-risk pregnant women in Muskegon County through a cost-benefit analysis. CHWs are selected, trained and working in the communities from which they live. The role of the community health worker is extremely diverse, usually due to the communities and programs that they serve. Their purpose is to improve health outcomes in the communities they serve by increasing access to and coverage to basic health services and needs, notably for underserved and medically needy populations. Previous studies have showed that CHWs have a positive effect on the healthcare system and overall health outcome for the population.
However, there are limited studies available that specifically analyze the effects of CHWs in a cost-benefit analysis to measure the outcomes created, especially for CHWs targeting at-risk pregnant women. To assess the effectiveness of such a program, program data from The Pregnancy Pathways Pilot Program, which is operated by the Muskegon Community Health Project, and claims data from Mercy Health Partners were used to calculate the estimates of potential health benefits and cost-savings.
The Muskegon Area Pregnancy Pathways Pilot Project appears to have been successful in preventing the occurrences of low weight births for the 7 program participants. All 7 newborns fell within the acceptable standard of 2500 – 4500 grams. Of the 7 newborns, 6 of them were considered to be healthy but one was considered to have problems. When the total costs of the clients‘ normal newborns from the 2500 – 4500 grams group were compared to neonates with problems with a low birth weight delivered by non-program mothers, there was an average savings of $337.75 per participant in this study.

▼ My dissertation research offers insights about the effects of Medicaid managed care (MMC) programs from Kentucky’s statewide market-based program. Kentucky’s significant reforms to introduce a comprehensive MMC program just one year after the passage of the ACA can provide valuable lessons for other rural states with substantial poor populations. In the first study, I explore Kentucky’s 2011 introduction of MMC and the quality of hospitals used by Medicaid recipients. Kentucky’s MMC program is a post-Affordable Care Act (ACA) market-based program that uses a small set of competing managed-care organizations (MCOs) to administer Medicaid benefits. Using a quasi-experimental research design, I explore whether the introduction of MMC changes the hospitals used by pregnant Medicaid-insured mothers for their deliveries and whether the quality of these hospitals is different compared to the hospitals used before the policy change. I also test whether the changes in hospitals used by pregnant Medicaid-insured mothers for their deliveries differ in smaller counties with fewer hospitals and Medicaid recipients compared to those in larger counties with more hospitals and Medicaid recipients. My analysis uses hospital quality measures designed by the Agency for Healthcare Research and Quality to measure hospital quality. I find that Medicaid-insured pregnant women from nonmetropolitan counties have an increased probability of delivering in the highest quality local hospitals as opposed to the lowest quality local hospitals. In contrast, I find that Medicaid-insured pregnant women from metropolitan counties have a decreased probability of delivering in the highest quality local hospitals and increased probability of delivering in lower quality local hospitals. Since Kentucky’s metropolitan counties have high quality hospitals and its nonmetropolitan counties have some of the poorest quality hospitals in the state, these findings may be positive for patient outcomes and program costs. Additional research evaluating patient outcomes and identifying the causal mechanisms responsible for changes in the hospitals used by Medicaid recipients is needed. Motivated by my findings in the first chapter, in my second chapter I exploit Kentucky’s reforms to explore potential mechanisms that link MMC to changes in the hospitals used by Medicaid-insured pregnant women for their deliveries. I focus on hospital network status and physician-hospital arrangements, which are the terms by which physicians practice in hospitals. These arrangements can affect the hospital ultimately used by physicians’ patients and may be designed specifically for the purposes of joint contracting with insurers. After using reduced form hospital choice models to estimate the change in the hospitals used by pregnant women in Kentucky in response to the introduction of MMC, I introduce measures of hospital network status and physician-hospital arrangements to my analysis. The primary policy effects on the hospitals used by Medicaid-insured women for…
Advisors/Committee Members: Sloan, Frank A (advisor), Ubel, Peter (advisor).

► The effects of pharmaceutical treatment on patient health, pricing of pharmaceuticals and their regulation are the backbone of my research. My work reflects two…
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▼ The effects of pharmaceutical treatment on patient health, pricing of pharmaceuticals and their regulation are the backbone of my research. My work reflects two current trends used to advance our knowledge in the field: the use of dynamic structural models that is supplemented by detailed administrative individual-level data.
This thesis consists of three chapters that address a number of policy-relevant questions in health economics using both individual- and market-level outcomes. In the first chapter I take a market-level approach to look at the effect of mergers between insurance companies on Medicare Part D plan premiums and generosity of coverage. In the following two chapters I study the effects of ADHD treatment on children's health and behavioral outcomes.
Advisors/Committee Members: Dr. Daniel Miller, Dr. Thomas Mroz, Dr. Michael Maloney, Dr. Raymond Sauer, Dr. Chungsang Lam.

▼ The majority of insured Americans obtain health insurance coverage
through employment as a non-portable fringe benefit. The link between health
insurance coverage and employment could have potential important implica-
tions on workers’ labor market decisions. My dissertation consists of three chapters that contribute to the understanding of the interaction between health insurance and workers’ job mobility.
My first chapter studies the effect of the state dependent coverage man-
dates on the job mobility of young adults. Prior to the Affordable Care Act, many states had already implemented insurance mandates that extended the age that young adults could gain access to parental health insurance, an alternative insurance source which is not contingent on employment. If young workers with employer-sponsored insurance (ESI) are locked into less preferred jobs for fear of losing health benefits, expanded dependent coverage is expected to reduce the job lock and increase mobility. Expanded eligibility could also decrease mobility among those who are pushed out of a better matched but uninsured job in search of access to ESI (job push). Using Survey of Income and Program Participation (SIPP) 2000-2010 data, the impact of the state mandates on job mobility is identified by a triple-difference framework that exploits the state level dependent coverage variations in eligibility criteria, mandate implementation states, and mandate implementation time. Results show that expanded dependent coverage led to a 5% decrease in the mobility
of workers with no ESI (job push). I find no evidence of reduced job lock.
The second chapter of my dissertation extends the analysis of my first chapter to the Affordable Care Act (ACA) Dependent Coverage Mandate.
The ACA Dependent Coverage Mandate was passed on March 23rd, 2010, and became effective on September 23, 2010. The mandate requires that health insurance plans that provide dependent coverage must cover dependents until the age of 26. Using SIPP 2008-2013 data, and both difference-in-difference framework and regression discontinuity design, I find consistent evidence of reduced job push and no evidence of reduced job lock. The estimated reduced job push is larger than the state analysis.
The third chapter studies the impact of the ACA Medicaid expansion on
childless adults’ job mobility. The ACA Medicaid expansion raised the Medi-
caid income eligibility threshold to 138% of the Federal Poverty Line (FPL) for everyone including childless adults who were not the traditional beneficiaries of the Medicaid. 32 states adopted the expansion while 19 states opted out. The reform could potentially increase childless adults’ job mobility if they are “locked” in their jobs for fear of losing employer-sponsored health insurance. Using the 2011-2016 basic monthly Current Population Survey (CPS), this paper tests this hypothesis by comparing the job mobility of childless adults
in expansion states to those residing in non-expansion states, before and after the expansion. Results show the existence of…
Advisors/Committee Members: Trejo, Stephen J., 1959- (advisor), Cabral, Marika (committee member), Geruso, Michael L (committee member), Olmstead, Todd A (committee member).

▼ Introduction. Early Intensive Behavioral Interventions (EIBI) is an applied behavior analysis approach that can be effective for remediating autism spectrum disorder (ASD) symptoms for some individuals (Reichow, 2012). From a population perspective, timely access to early intervention services is assumed to be important for facilitating long term positive educational outcomes. Stakeholders report, however, long waitlists for services. The range of effects of EIBI service delay on educational outcomes for children with ASD is unknown. The purpose of the study was to examine how EIBI service delays relate to later educational and placement outcomes for Medicaid-enrolled children diagnosed with ASD. Three research questions guided the analyses conducted in this study: 1) what is the main effect of delay to EIBI on educational outcomes, 2) what is the main effect of average hours of EIBI per week on educational outcomes and 3) does the average delay to start EIBI differ by county or region within Minnesota? Method. The study utilized cross-systems administrative data to create a cohort of 3 to 5 year olds who received a diagnosis of ASD between 2008 and 2010. This cohort was matched with Minnesota Department of Education (MDE) records from the 2010-2014 academic year (94.5% match rate). Delay to EIBI services in months was calculated by subtracting the date of ASD diagnosis (ICD-9 CM 299.0) from the first billing date associated with an EIBI service provider. Educational outcomes evaluated included primary educational ASD diagnosis, instructional placement, Minnesota Comprehensive Assessment-III (MCA) scores and special education service hours. Descriptive analyses, Generalized Estimating Equations regressions models (GEE), and Geographic Information Systems (GIS) were used to evaluate data from 667 children with ASD (82% Male, 72% White). Results. The average delay to EIBI was 8.99 months (SD=10.63 mos). At follow-up, 94% of the cohort qualified for special education with 70% of them receiving an ASD diagnosis in school. About 40% of the children received a general education placement. The GEE models calculated showed that the main effect of delay to EIBI was significant and the odds of receiving a general education placement and participating in the MCA- tests was decreased if the child experienced a longer delay to start EIBI. Additionally, the odds of receiving a primary educational diagnosis of ASD increased for every increase in delay. The results further suggest that the main effect of average hours of EIBI per week was significantly associated with ASD diagnosis in school, MCA participation, and special education service hours. Finally, children who resided in the metro area (M=9.89 mos, SD=11.24 mos) had a larger average delay to EIBI compared to children who resided in the non-metro area (M=7.00 mos, SD=8.78 mos). Discussion. With increases in diagnoses of ASD over the past decade, it is imperative that children and families have early access to high quality services. Children who were diagnosed younger and…

Dimian, A. (2017). The impact of a delay to early intensive behavioral intervention on educational outcomes for a cohort of medicaid-enrolled children with autism. (Doctoral Dissertation). University of Minnesota. Retrieved from http://hdl.handle.net/11299/188847

Chicago Manual of Style (16th Edition):

Dimian, Adele. “The impact of a delay to early intensive behavioral intervention on educational outcomes for a cohort of medicaid-enrolled children with autism.” 2017. Doctoral Dissertation, University of Minnesota. Accessed January 21, 2019.
http://hdl.handle.net/11299/188847.

MLA Handbook (7th Edition):

Dimian, Adele. “The impact of a delay to early intensive behavioral intervention on educational outcomes for a cohort of medicaid-enrolled children with autism.” 2017. Web. 21 Jan 2019.

Vancouver:

Dimian A. The impact of a delay to early intensive behavioral intervention on educational outcomes for a cohort of medicaid-enrolled children with autism. [Internet] [Doctoral dissertation]. University of Minnesota; 2017. [cited 2019 Jan 21].
Available from: http://hdl.handle.net/11299/188847.

Council of Science Editors:

Dimian A. The impact of a delay to early intensive behavioral intervention on educational outcomes for a cohort of medicaid-enrolled children with autism. [Doctoral Dissertation]. University of Minnesota; 2017. Available from: http://hdl.handle.net/11299/188847

► Over the last several decades, most states have increasingly shifted their Medicaid long-term care (LTC) expenditures away from primarily institutional services toward more home and…
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▼ Over the last several decades, most states have increasingly shifted their Medicaid long-term care (LTC) expenditures away from primarily institutional services toward more home and community-based services (HCBS). Despite the increase in HCBS, the risk for potentially preventable hospitalizations among elderly Medicaid HCBS users is largely unknown. Given the health implications and the high cost of hospitalizations, it is important to better understand potentially preventable hospitalizations among these LTC users. This dissertation research empirically examined potentially preventable hospitalizations among elderly Medicaid LTC users in community and institutional settings. Specifically this research aimed to (1) identify the factors associated with potentially preventable hospitalizations among elderly Medicaid HCBS users, (2) compare the risk for a potentially preventable hospitalization between elderly Medicaid HCBS users and nursing home residents, and (3) compare the risk for a potentially preventable hospitalization between elderly Medicaid LTC users who transition from a nursing home to a home or community LTC setting and those who remain in a nursing home. Results from these analyses found that potentially preventable hospitalizations were frequent among elderly Medicaid HCBS recipients, and a few conditions accounted for the majority of these hospitalizations. Several characteristics were significantly associated with an increased risk for a potentially preventable hospitalization suggesting that there is variation in preventable hospitalizations among the elderly Medicaid HCBS population and improvements could be made in reducing this variation. After controlling for a number of characteristics and correcting for endogeneity, HCBS users had an increased risk for a preventable hospitalization compared to nursing home residents. More proactive medical care and policies focusing on reducing hospitalizations may be needed for the HCBS population, as well as better aligned incentives for providers to coordinate care. Elderly Medicaid LTC users who transitioned from a nursing home to using HCBS had an increased but non-significant risk for a preventable hospitalization compared with individuals who remained in the nursing home. The medical care and continuity of providers within the nursing home setting are likely important factors in keeping nursing home residents out of the hospital.

► The purpose of the study was to characterize and compare demographic and clinical characteristics, treatment patterns (i.e., medication adherence, persistence, addition, and switching), and healthcare…
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▼ The purpose of the study was to characterize and compare demographic and clinical characteristics, treatment patterns (i.e., medication adherence, persistence, addition, and switching), and healthcare utilization and cost (i.e., all-cause and epilepsy-related) associated with refractory or non-refractory epilepsy. The study used Texas Medicaid claims data from 09/01/07-12/31/13. Prescription and medical service claims of eligible patients analyzed over a 30-month study period comprised of a 6-month pre-period (baseline) and a 24-month follow-up period (annual increments). Patients eligible for the study: 1) were between 18-62 years of age, 2) had a prescription claim for an antiepileptic drug (AED) during the identification period (03/01/08-12/31/11) with no baseline use of an AED and no prophylactic use of an AED at follow-up, and 3) had evidence of epilepsy diagnosis during the study period. Additionally, patients had to be continuously enrolled in Texas Medicaid with no dual eligibility for Medicare and Medicaid. The index date for both the cohorts was the date of the first AED claim. Dependent variables included: treatment patterns, healthcare utilization and cost. The primary independent variable was group (i.e., refractory vs. non-refractory epilepsy). Based on clinical expert opinion and the literature, patients were categorized as “refractory” (i.e., three or more AEDs, excluding diazepam, in the identification period) and “non-refractory” (i.e., less than three AEDs in the identification period). The covariates included age, gender, race/ethnicity, type of epilepsy, type of index AED, baseline CCI, number of psychiatric comorbidities and presence of non-psychiatric comorbidities at follow-up, baseline pill burden, presence of baseline all-cause inpatient visits, baseline number of all-cause outpatient visits, and baseline all-cause total cost. Using a retrospective matched-cohort design, patients in the refractory cohort were matched 1:1 to patients in the non-refractory cohort using propensity scoring. The matched cohorts were compared for treatment patterns and healthcare utilization and costs using multivariate conditional regression models and non-parametric methods.
Of the 10,599 eligible patients, 2,789 (26.3%) patients in the refractory cohort were matched 1:1 to patients in the non-refractory cohort for a total of 5,596 patients. Mean (± SD) age of the patients in the matched cohort was 38.0 (± 13.1) years, and the cohort was comprised of a higher proportion of females (56.0%), Caucasians (41.9%), patients with other convulsions (77.2%), and those with claims for sodium channel blockers (35.4%). A higher proportion of patients with refractory epilepsy were initiated on combination AEDs (26.5% vs. 10.7%), followed by GABA analogues (12.0% vs. 10.2%), and calcium channel action agents (7.7% vs. 3.4%) compared to patients with non-refractory epilepsy. During the second year of follow-up, patients with refractory epilepsy had a higher mean (± SD) (2.1 [± 1.5] vs. 1.8 [± 1.4]) number of psychiatric…
Advisors/Committee Members: Wilson, James P. (advisor), Barner, Jamie C. (advisor), Hovinga, Collin A (committee member), Rascati, Karen L (committee member), Richards, Kristin M (committee member).

► Nursing home residents in the United States are frequently hospitalized. Such hospitalizations are costly, many are considered unnecessary and lead to further health deterioration. Controlling…
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▼ Nursing home residents in the United States are
frequently hospitalized. Such hospitalizations are costly, many are
considered unnecessary and lead to further health deterioration.
Controlling for health status, Medicaid residents have been found
to have a higher risk of hospitalization than private-pay
residents, but the reasons for this difference are not clear. The
higher rate of hospitalization may be caused by within-facility
disparities between Medicaid and private-pay residents.
Alternatively, it may also be caused by across-facility variations,
whereby facilities with a higher proportion of Medicaid residents
may be more likely to hospitalize their residents than facilities
with lower proportion of Medicaid residents. This dissertation aims
to disentangle the within-facility disparities from the
across-facility variations in hospitalization risks between
Medicaid and private-pay residents, and to investigate the impact
of financial incentives.
Multiple datasets from four states
(California, New York, Ohio, and Texas) for calendar year 2003 are
employed in this study. The study sample includes all eligible
long-term care residents with either Medicaid or private payer
status. The unit of analysis is the individual resident with
hospitalization as the dependent variable (dichotomous). Individual
payer status and facility payer-mix are the main variables of
interests. Additional covariates include individual risk factors,
co-morbidities, facility characteristics, and market level factors.
Several logit models are fit to investigate payer-related
within-facility disparities versus across-facility variations.
Analyses are stratified by state and ownership, and responses to
financial incentives are tested statistically to make inferences
about hypotheses regarding Medicaid bed-hold polices and for-profit
versus not-for-profit responses to incentives. Furthermore,
hospitalization rates for Medicaid and private-pay residents are
compared across the four states by using standard populations.
Results show that Medicaid residents are more likely to be
hospitalized than private-pay residents, controlling for individual
risk factors. Higher hospitalization rates experienced by Medicaid
residents can be attributed to both within-facility disparities and
across-facility variations. Payer-related within-facility
disparities in hospitalization risks exist in most facilities, and
are modified by facility characteristics (e.g. ownership) and state
Medicaid policies (e.g. bed-hold policy). Across-facility
variations are also detected in most of the facilities. Nursing
homes with a higher concentration of Medicaid residents are more
likely to hospitalize their residents, regardless of the residents’
payer status. In addition, hospitalization rates for Medicaid and
private-pay residents are found to vary across states.
In
conclusion, this dissertation finds that for-profit facilities are
more likely to be affected by financial incentives than
not-for-profit facilities with respect to hospitalization
decisions. Bed-hold policy…

► This dissertation considers changes of health insurance system of United States that affect health outcomes and labor market outcomes of population. The first chapter examines…
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▼ This dissertation considers changes of health
insurance system of United States that affect health outcomes and
labor market outcomes of population. The first chapter examines how
Medicaid policy aimed to improve health status of low-income
parents affects the health outcomes of young children. Estimates
from variations in Medicaid rules across states and over time, show
that there exist positive spillover effects on children from
Medicaid expansions targeting parents. The child mortality declines
more in states with higher level of generosity in Medicaid policy
and the effect is larger among black children. Simulations indicate
that recent Medicaid expansion under Affordable Care Act Reform can
deepen the existing child mortality disparity across states due to
different adoption of Medicaid expansion for low income adult
population. The second chapter examines Massachusetts health care
reform and its impact on labor market outcomes of older males
approaching retirement. I find that older males are more likely to
remain in full-time employed status rather to choose early
retirement, and part-time employment increased only among
low-income population who are eligible for subsidized health
insurance. The results suggests that there exists employment-lock
effect from increase of employers providing employersponsored
health insurances following the reform.
Advisors/Committee Members: Andrew Beauchamp (Thesis advisor), Mathis Wagner (Thesis advisor).

► This paper details several factors that affect Medicaid, the federal program that provides health care reimbursement for millions of low-income Americans. The research presents many…
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▼ This paper details several factors that affect Medicaid, the federal program that provides health care reimbursement for millions of low-income Americans. The research presents many challenges to sustaining an equitable welfare system that also produces positive health outcomes. Growing levels of poverty have resulted in increased enrollment in the Medicaid program and projections indicate a continuation of this trend. A decrease in the supply of physicians along with an aging population creates new obstacles to health care access. The Patient Protection and Affordable Care Act (PPACA) introduces additional complexities by expanding Medicaid enrollment, increasing regulatory requirements and reducing payments to health care providers through rate cuts and penalties.
Advisors/Committee Members: Reagan, Daniel J. (advisor).

► The June 2012 Supreme Court decision concluded that all provisions of the Affordable Care Act were constitutional except for the mandatory Medicaid expansion for adults.…
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▼ The June 2012 Supreme Court decision concluded that
all provisions of the Affordable Care Act were constitutional
except for the mandatory Medicaid expansion for adults. Therefore,
each state had the option to expand Medicaid. By 2015, thirty-one
states had adopted Medicaid expansion. Medicaid expansion is
generally supported by Democrats and resisted by Republicans. Given
the power governors have in Medicaid policymaking, it would stand
to reason that states with Democratic governors would expand while
states with Republican governors would not. However, ten states
adopted expansion with a Republican governor. In the context of
widespread Republican opposition to the ACA, why did some
Republican governors support Medicaid expansion? What factors
influence Republican governors’ decisions regarding Medicaid
expansion? The overall goal of this study is to understand the
conditions under which Republican governors decided to support
Medicaid expansion, given their party’s opposition. Using mixed
methods, the specific aims of this study are: 1) Identify the
factors associated with a Republican governor’s decision to support
Medicaid expansion.2) Determine in-depth how these factors and
perhaps others, interacted with Republican governors in two states
– one expansion state (Arizona) and one non-expansion state
(Florida). The results from this study imply that in the case of
Medicaid expansion, ideological, economic, political, and racial
factors influence the decision-making of Republican governors, with
ideological factors being the most dominant.The implications of
this study are extensive for stakeholders including policymakers,
public health advocates, interest groups, and researchers in states
with Republican governors. It offers statistical and qualitative
data that can be used to help them identify potential problems and
solutions for coverage expansions in the future in seemingly
challenging circumstances. Moreover, findings from this study can
help stakeholders in favor of Medicaid expansion illuminate the
conditions in which coverage expansion may be difficult or
relatively easy as well as help them explain why. Learning more
about what drives expansion of coverage in challenging
circumstances is important as these expansions contribute to making
health care more accessible, equitable, and affordable,
particularly for low-income and vulnerable
populations.
Advisors/Committee Members: Tanenbaum, Sandra (Committee Chair).

Prater, W. (2018). To Expand or Not Expand Medicaid? That is the Republican
Governor’s Question. (Doctoral Dissertation). The Ohio State University. Retrieved from http://rave.ohiolink.edu/etdc/view?acc_num=osu152813205087059

Chicago Manual of Style (16th Edition):

Prater, Wesley. “To Expand or Not Expand Medicaid? That is the Republican
Governor’s Question.” 2018. Doctoral Dissertation, The Ohio State University. Accessed January 21, 2019.
http://rave.ohiolink.edu/etdc/view?acc_num=osu152813205087059.

Prater W. To Expand or Not Expand Medicaid? That is the Republican
Governor’s Question. [Internet] [Doctoral dissertation]. The Ohio State University; 2018. [cited 2019 Jan 21].
Available from: http://rave.ohiolink.edu/etdc/view?acc_num=osu152813205087059.

Council of Science Editors:

Prater W. To Expand or Not Expand Medicaid? That is the Republican
Governor’s Question. [Doctoral Dissertation]. The Ohio State University; 2018. Available from: http://rave.ohiolink.edu/etdc/view?acc_num=osu152813205087059

► The Arkansas premium assistance model, commonly known as the Private Option, is one of six alternative Medicaid waiver designs that have been approved in states…
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▼ The Arkansas premium assistance model, commonly known as the Private Option, is one of six alternative Medicaid waiver designs that have been approved in states to expand coverage for low-income adults. The waiver places adults age 19-64 and under 138% of poverty in the newly established health insurance exchange and uses Medicaid funding to purchase the premium payment for health plan coverage. The program began in January 2014. This qualitative descriptive study examined the key operational and program features of the Private Option in order to provide a formative evaluation of how well it is working at this early stage. The study also examined if this model, or similar models, might offer a promising path for the 19 states that have chosen not expand coverage for populations newly eligible for Medicaid under the Affordable Care Act.; The results of the study suggest that it is a potentially promising model. Arkansas saw the largest drop in the uninsured rate in the country in the first 18 months since the program began. It has also expanded its provider networks, added new health plans to the marketplace, and the program is generating overall net state savings. Politics, policy, and state costs are factors that drive the current debate in states that have not expanded. Framing coverage as a uniquely designed state approach and not Medicaid expansion are key conditions for moving forward. Language emphasizing a private sector approach and personal responsibility are critical factors as well.; There are challenges, however, between Medicaid rules and exchange rules, particularly around the issue of cost-sharing. There is a significant cliff between the two programs in terms of personal financial obligations that will likely need to be remedied in the years ahead. Studies show that as many as 50% of those under 200% of poverty are likely to transition between eligibility for these two programs in any given year, and these cost-sharing differences apply despite an integrated program. The Affordable Care Act is part of an ongoing process that has transformed Medicaid from a social welfare program to an income-based program to provide health insurance coverage to low-income populations. The integration of these two programs, Medicaid and the health insurance exchanges, through premium assistance, reflects these transformative changes and are part of the continuing evolution of our nation's health care system.

► EMTALA requires Medicare-participating hospitals to provide emergency care to all patients regardless of payer. We examine the effect of EMTALA in three studies. (1) In…
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▼ EMTALA requires Medicare-participating hospitals to provide emergency care to all patients regardless of payer. We examine the effect of EMTALA in three studies. (1) In key informant interviews, we examine causes for and solutions to EMTALA noncompliance. We find that hospitals may violate EMTALA for five reasons: financial pressure, complexity/lack of knowledge about the law, a high referral burden that makes it difficult to comply with EMTALA, inter-hospital relationships that discourage reporting on borderline inappropriate transfers, and a principal-agent problem with differing physician and hospital priorities. We propose several ways to strengthen the Act, including requiring Medicaid to fully reimburse required EMTALA screening exams and amending EMTALA to permit informal mediation sessions between hospitals. (2) We measure changes in hospital utilization and readmissions when EMTALA is extended to inpatients. In 2009, the Federal Court of Appeals for the Sixth Circuit ruled that EMTALA obligations continued until a patient was stabilized, regardless of whether s/he was admitted. However, hospitals outside the court’s jurisdiction continued to follow 2003 regulations that EMTALA obligations cease after a good faith admission. This study uses a difference-in-difference-in-differences design, comparing Medicaid/uninsured with commercially-insured patients before and after the case in hospitals inside and outside the Sixth Circuit. We find that although more unprofitable inpatients are discharged with a short length of stay after extending EMTALA to inpatients, they are substantially less likely to be readmitted. These results suggest that extending EMTALA to inpatients may encourage hospitals to fully stabilize unprofitable patients admitted from the emergency department (ED).(3) We explore whether hospitals strategically avoid treating uninsured and Medicaid patients by temporarily closing part of their EDs (through an ambulance diversion) when nearby safety net hospitals declare diversion. We find that hospitals are more likely to declare diversions when nearby safety net hospitals go on diversion, as compared to when nearby non-safety safety net hospitals (matched by size and distance) do so. Furthermore, hospitals that divert when a nearby safety net hospital diverts have a slightly lower ED occupancy than hospitals that divert when a nearby non-safety net hospital diverts. In addition, we theorized that, like musical chairs, hospitals do not want to be last one with an open ED after a nearby safety net hospital declares a diversion. Consistent with this theory, when multiple hospitals in a market are on diversion, the third hospital in a market to declare a diversion does so sooner if the first hospital declaring a diversion is a safety net hospital than if the first hospital is a non-safety net hospital. Hospitals also end their diversions differently depending on whether the nearby diverting hospital was a safety net hospital or non-safety net hospital. Specifically, hospitals are on…

► The purpose of this dissertation study was to describe selected processes and outcomes variables for Medicaid beneficiaries enrolled and giving birth with American Association of…
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▼ The purpose of this dissertation study was to describe selected processes and outcomes variables for Medicaid beneficiaries enrolled and giving birth with American Association of Birth Centers Center for Medicare and Medicaid Innovation Strong Start sites between 2012 and 2014. The goal was to examine the relationships between selected care processes and outcomes of childbearing Medicaid beneficiaries to inform research, practice, and policy. Processes of care and the outcomes of Medicaid beneficiaries receiving care within the model exceeded national quality benchmarks, demonstrated resistance to unwarranted variation, and led to increases in effective care and preference sensitive variations. Supply-sensitive variations were demonstrated within the sample of Strong Start sites with the elective hospitalization of healthy, medically-low-risk women leading to significantly more cesarean sections than women choosing home or birth center admission in labor. The dissertation contributes to scientific knowledge and supports expansion of the model among Medicaid beneficiaries nationwide.
Advisors/Committee Members: Langford, Rae W. (advisor), Langford, Rae W. (advisor), Cesareo, Sandra (advisor), Koci, Anne (advisor), Stapleton, Susan (advisor).

► With states facing tightening Medicaid budgets, the high cost of financing long-term care for the elderly through Medicaid has prompted proposals to make private long-term…
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▼ With states facing tightening Medicaid budgets, the high cost of financing long-term care for the elderly through Medicaid has prompted proposals to make private long-term care insurance (LTCI) more affordable through tax incentives. The effectiveness of tax incentives for stimulating LTCI demand depends in part on the availability of Medicaid, since it is considered a substitute for LTCI. This paper examines the impact of tax subsidies and Medicaid financing on the demand for LTCI by developing and estimating a stochastic dynamic model of the decision to purchase private long-term care insurance. A key contribution of this paper is that the model also incorporates and accounts for endogenous decisions on Medicaid enrollment, nursing home use, and asset holdings, which reduces the estimate of the Medicaid crowd-out effect on LTCI demand. State-specific Medicaid enrollment criteria are explicitly accounted for in modeling the Medicaid enrollment decision. The parameters of the model are estimated using individual level data from the Health and Retirement Study for the years 1998 to 2002 by simulated maximum likelihood. Using the estimated parameters, counterfactual policy experiments are performed to investigate the effects of tax policy and Medicaid on LTCI demand. The main finding is that both effects are small. The estimated price elasticity of the LTCI demand is -0.08, implying that tax subsidies are expected to have only a limited effect in reducing the number of uninsured. Eliminating the Medicaid program increases LTCI holding by only 5.3%, implying that the demand for LTCI would remain small even without Medicaid.

► This dissertation examined if and how the recent initiatives aimed at improving health care access of underserved populations were effective. The U.S. government has long…
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▼ This dissertation examined if and how the recent initiatives aimed at improving health care access of underserved populations were effective. The U.S. government has long relied on strategies of subsidizing or providing health insurance and strategies of increasing the availability of free or lower cost services as critical means of improving health care access for underserved populations or areas. This dissertation particularly focused on the recent governmental initiatives under the Patient Protection and Affordable Care Act (ACA) with such efforts. Each paper investigated how various components of the ACA may improve population health and financial well-being, including: i) how insurance market reform initiatives, including partial Medicaid expansion, have impacted individuals' affordability of care; ii) how the Medicaid expansion may have differentially affected hospitals uncompensated care burden; and, iii) how the ACAs federal funding growth for health centers have improved primary care access. The first paper estimated how the ACAs set of public and private insurance market reforms have affected underinsured rates of entire-year insured people, and how the changes between before and after the ACA varied by peoples income groups and high-risk of utilizing health care groups. Using the 2008-2015 Medical Expenditure Panel Survey and interaction terms in the linear regression models, the study found that differential changes in financial burden after ACAs set of insurance initiatives were significantly different between low and high income groups. The differential changes between those with and without chronic conditions were also significant, however, the magnitude of differential changes were small.The second paper estimated how Medicaid expansion under the ACA has affected hospitals uncompensated care provision, and how the changes following the partial Medicaid expansion may have varied by hospitals Medicaid Disproportionate Share Hospital (DSH) status. Using the 2011-2015 Medicare Cost Reports, Medicaid DSH Audit Reports, Area Health Resources File (AHRF) data, and difference-in-differences and triple differences approaches, the study found that while Medicaid expansion significantly reduced hospitals uncompensated care provision, the changes were not significantly different between Medicaid DSH hospitals and non-DSH hospitals. The third paper estimated how changes in funding for health center programs, including those implemented under the ACA, may affect hospitalizations of people with potentially preventable conditions, which could be avoided with timely and effective ambulatory care. Using a county-level longitudinal panel dataset constructed with the 2009-2013 Healthcare Cost and Utilization Project State Inpatient Databases, Uniform Data System, and AHRF, the study estimated linear regressions including year and county fixed effects for Florida, Kentucky, and New York. The study did not find that federal funding growth for health centers significantly affected potentially preventable hospitalization…
Advisors/Committee Members: Joel E Segel, Dissertation Advisor.

► Purpose: To assess the effect of dental Medicaid reforms in the state of Virginia on dental plan performance. Methods: This project is a retrospective cohort…
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▼ Purpose: To assess the effect of dental Medicaid reforms in the state of Virginia on dental plan performance.
Methods: This project is a retrospective cohort study of 825,000 dental claims obtained from the Virginia Department of Medical Assistance Services. This cohort includes dental claims for children enrolled in Virginia’s Medicaid program from July 1, 2002 through June 30, 2008. The independent variable was enrollment pre or post policy reform with July 1, 2005 as the period dividing date. The dependent variable was dental benefit utilization measured as the average number of restorative, preventative, and total procedures. Statistical methods include Welch’s t-test and repeated measures mixed model ANOVA controlling for gender, race, age, length of enrollment, gaps in patient enrollment, citizenship status, and geographic location.
Results: This cohort of data showed a significant increase in the total number of procedures utilized by enrolled children (P value < 0.001). There were also significant increases in restorative services across all periods of enrollment.
Conclusion: The consolidation of Virginia’s multiple managed care programs into a single vendor with increased reimbursement levels resulted in increased in access to care and improved utilization of dental services for children enrolled in Medicaid.
Advisors/Committee Members: Elizabeth Berry, Tegwyn Brickhouse.

► Diabetes mellitus is a group of metabolic disorders that has many long-term consequences costing $132 billion annually, a figure that can be improved with proper…
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▼ Diabetes mellitus is a group of metabolic disorders that has many long-term consequences costing $132 billion annually, a figure that can be improved with proper management. Previous long-term prospective studies have demonstrated that tight glycemic control will prevent and delay the development of subsequent complications. Consequently, the American Diabetes Association (ADA) recommends daily self-monitoring of blood glucose (SMBG) to achieve tight glycemic control, but mot diabetic patients do not practice SMBG. This study examined the association between the number of blood glucose monitoring reagent strips dispensed and the total diabetic medical and pharmacy cost in a Utah Medicaid population. Separate regression models were developed for diabetics treated with insulin and oral antihyperglycemic agents. This study found 7.3% of the patients enrolled in Utah Medicaid practiced SMBG according to the ADA guidelines. In this sample, patients using insulin and receiving a medium to high number of strips were estimated to have 40% - 53% higher medical cost than patients who received no strip during the same year. Level of AMBG, however, did not appear to affect total diabetes-related medical costs in the insulin group. Nevertheless, total diabetes costs trended upwards at the number of strip obtained increased. Similarly, oral patients were estimated to have 54% higher medical costs for adherent level of SMBG and a trend for higher diabetes cost as the number of strips obtained increased. Patients who obtained strips had higher resource utilization even after controlling for Comorbidity, visits and prior year medical costs. It is unlikely that the use of strips causes an increase in health resource utilization, but it is plausible that variables associated with strip use and increased medical costs are not adequately represented in the statistical models. The observation from this study to no support the growing evidence found in commercial market the positive economic impact of strips coverage for SMBG; however, the program does not provide assess for patient to improve self-efficacy and reduce dependency on medical care for control in the long-term. Longer prospective studies should be conducted to determine long-term outcomes in this population.